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Objective: A comprehensive overview of the surgical treatment of vulvar cancer, including recurrent forms. Methodology: A review work providing a basic overview of the pathogenesis, dia gnosis and surgical treatment of vulvar cancer with a focus on the possibilities of treatment of its recurrences. It includes an illustrative case report presenting a patient with invasive squamous cell carcinoma of the vulva with iterative local recurrences and subsequent development of tumor triplicity and distant metastatic involvement. Conclusion: Surgical treatment remains the main modality of vulvar cancer therapy, even in the case of locally advanced or recurrent findings. In these cases, multidisciplinary cooperation of operational fields is necessary. The discipline of treated patients with participation in regular dispensary care plays an important role in the early detection of recurrences. (Chemo)radiotherapy remains a possible alternative to the surgical solution; in clinical practice, radiotherapy has an irreplaceable place in adjuvant therapy. Regional and distant recurrences are characterized by a poor prognosis. Key words: vulvar cancer – surgery – local recurrence – groin (inguinal) recurrence – distant recurrence – chemoradiotherapy

Objective: Analysis of our approach to breast reconstruction after mastectomy in women with breast cancer and/or BRCA mutations. Oncoplastic surgery enables procedures that are sufficiently radical and with a very good cosmetic effect. With the development of genetic testing programs, the need for prophylactic procedures is also increasing. One-sided curative performance and at the same time prophylactic surgery on the other breast can be used. Methods: We use the possibility of immediate breast reconstruction simultaneously with subcutaneous and skin-saving mastectomy. We solve the reconstruction either with an expander and in the second time by inserting a silicone implant, or directly by inserting the implant alone or in combination with the use of autologous tissue, depending on further oncological treatment (chemotherapy or radiotherapy). Results: One-hundred and three reconstructive surgeries were performed on 58 women with breast cancer and/or BRCA mutations from April 2017 to May 2020. Of these, there were 52 immediate reconstructions for untreated tumors. A tissue expander was inserted in 27 women (46.6% of the group) with locally advanced tumors and the need for subsequent radiotherapy (18 immediate and 9 delayed reconstructions). Breast implants were used in 52 women (89.7% of the group) in a total of 80 implants. Breast reconstruction of own tissues was performed in 8 women, of which 5 operations had immediate reconstruction. Postoperative complications occurred in 11 women and 15 corrective procedures were performed (12.7% of operations). Conclusion: Breast reconstruction is a comprehensive set of techniques by which any patient can obtain a breast so that it does not depend on the epithelium. Patients with locally advanced disease who receive neoadjuvant chemotherapy and radiotherapy are at greater risk of complications. With the growing number of breast cancers, the demand for reconstructive procedures, especially immediate reconstructions, is increasing. Key words: breast cancer – BRCA mutations – mastectomy – breast implants – expander – immediate breast reconstruction – delayed recon-struction – tissue lobe

Introduction: In the last decade, the view of endometrial cancer has shifted enormously, and the surgical approach or lymph node staging has changed significantly. We are presenting these changes with the University Hospital Brno Oncogynecology center’s results in the years 2012–2021 in the actual national and European guidelines context. Methods: The retrospective unicentric observational study, national and European guidelines review. Results: In the observation period, 715 endometrial cancer patients were treated in our clinic, and 636 of them underwent surgical treatment (89%). Concerning lymph node staging, firstly, there is a clear trend of expanding lymphadenectomy to the paraaortic area, followed by the sentinel node biopsy introduction in the years 2018–2019, and finally, the complete transition to this method as the main staging procedure in 2021, when this examination was performed in 73% of surgeries, even with high-risk cancers limited to the uterus. Within the sentinel node biopsy expansion, a gradual decrease in laparotomy approach (maximum 41% in 2016, 18% in 2021), and blood loss (2012–2019 median 100 mL, with a decrease to 50 mL in 2020–2021) was evident. A hospitalization length stabilized at a median of 5–6 days. Conclusions: Surgical treatment of endometrial cancer has become a minimally invasive procedure for the majority of patients, the average blood loss and hospitalization length have decreased. Sentinel node biopsy has become the preferred lymph node staging method. Key words: endometrial cancer – lymphadenectomy – sentinel lymph node – total laparoscopic hysterectomy – uterine manipulator

Introduction/Background* The SENTIX is a prospective cohort international study on sentinel lymph node (SLN) biopsy without pelvic lymph node dissection (PLND) in patients with early-stage cervical cancer. The primary end point is a recurrence rate at 24 months´ follow-up after the surgery. Either magnetic resonance imaging (MRI) or expert ultrasound (EUS) was mandatory as a preoperative staging method. The aim of this study is to report the accuracy of preoperative local staging. Methodology Forty-seven sites from 18 countries participated in the study. Patients with stages T1a1/LVSI+ – T1b1 (FIGO 2009), common histological types and no suspicious lymph nodes on imaging were eligible. Patients were excluded from further study if SLN were not detected on both sides and if SLN was positive on frozen section histological evaluation. Compared were results from preoperative imaging with final pathology reports. Result(s)* From May 2016 to October 2020, 733 registered patients underwent surgery, 132 were excluded intraoperatively, data from 708 were analysed in this study. Patients’ characteristics are in table 1. Out of 90 patients clinically staged as 1A tumours, 42 (46.7%) were upstaged to IB1 (86% ≤ 2 cm, 14% 2-4cm, 0% > 4cm); 76.3% had conisation as diagnostic procedure. Fourteen out of 547 preoperatively IB1 tumours (2.6%) were upstaged to IB2 > 4cm. Analogously 33 patients (6%) with IB tumours were downstaged to IA. Preoperatively unrecognized parametrial involvement was found by pathology only in 22 out of 637 patients (3.5%). EUS and MRI were used equally in the study (53.5% vs 56.1%), both were comparable in the accuracy of tumour size measurement (2 cm size categories shift in stage IB) (p=1.000) and in the failure to detect parametrial involvement (2.9% vs 4.0%) (p=0.535). Chart 1. Conclusion* Clinical staging with EUS and MRI failed to detect positive parametria only in 3.5% of patients in the Sentix trial. Upstaging from IA tumours was frequent, mostly after previous conization. Only 2.6% of patients were upstaged to IB2 tumours >4 cm (IB3 FIGO 2018). Both EUS and MRI were equally reliable in tumour size and parametrial involvement assessment.

Endometrial cancer is the most common gynecologic malignancy in Europe and usually diagnosed in its initial stage owing to early symptoms of abnormal bleeding. There is no population screening for this disease, although it can sometimes be accidentally diagnosed in asymptomatic patients. Our study aims to determine differences in clinical and tumor characteristics between an asymptomatic and symptomatic group of patients. This unicentric prospective observational study took place in University Hospital Brno between January 2016 and December 2019. A total of 264 patients met inclusion criteria (26% asymptomatic, 74% with reported symptoms). We did not find a statistically significant difference in clinical characteristics (menopausal status, parity, age, BMI, and serum level of CA 125) between groups. According to ultrasound examination, bleeding tumors were larger (19.5 vs. 12.7 mm, p ≤ 0.001). Definitive histology results indicated more frequent lymphovascular space invasion (p &lt, 0.001), along with deep myometrial (p = 0.001) and cervical (p = 0.002) invasion. There was no difference in advanced stages of the tumor. We did not substantiate statistically significant difference in immunohistochemical profile (estrogen and progesterone receptors, L1 cell adhesion molecule, tumor protein p53), which is relevant for tumor recurrence risk and survival capacity. Our conclusions affirmed that bleeding occurs more often among patients with local tumor invasion into the myometrium and cervical stroma. Final International Federation of Gynecology and Obstetrics (FIGO) stage, histology, and immunohistochemical characteristics do not significantly affect symptom appearance.

Circulating tumor markers are not routinely used in patients with endometrial cancer (EC). This pilot study evaluated the role of monitoring new biomarkers DJ1 and L1CAM, in correlation with CA125 and HE4, for the effects of anticancer treatment and preoperative management in EC patients. Serial serum levels of DJ1, L1CAM, CA125 and HE4 were collected in 65 enrolled patients. Serum DJ1, L1CAM, CA125 and HE4 levels were significantly higher at the time of diagnosis compared to those measured during follow-up (FU). In patients with recurrent disease, serum DJ1, CA125 and HE4 levels were significantly higher at the time of recurrence compared to levels in disease-free patients. Serum L1CAM levels were also higher in patients with recurrence but without reaching statistical significance. While DJ1 levels were not affected by any of the observed patient-related characteristics, L1CAM levels were significantly higher in patients with age ≥60 years who were overweight. At the time of EC diagnosis, DJ1 and L1CAM serum levels did not correlate with stage, histological type or risk of recurrence. This is a preliminary description of the potential of serial DJ1 and L1CAM serum level measurement for monitoring the effects of treatment in EC patients.

This study aimed to evaluate the impact of the secondary cytoreductive surgery on survival parameters in women with platinum-sensitive recurrent ovarian cancer who undergone secondary cytoreduction following chemotherapy compared to women who recieved chemotherapy alone.In a retrospective study, data were rewieved from women who were diagnosed and treated with ovarian cancer and its primary platinum-sensitive recurrence at the University Hospital Brno in the Czech Republic between November 2009 and March 2016. Out of the total number of 62 patients with recurrence, 30 women underwent cytoreductive surgery plus chemotherapy and 32 were treated with chemotherapy alone. The good performance status expressed by ECOG score 0-1, the single site of recurrence regardless of platinum-free interval or multiple sites of recurrence but no carcinomatosis and platinum-free interval12 months, and no or small-volume ascites (500 ml) were considered inclusion criteria for cytoreductive surgery. Women not meeting these criteria were treated by chemotherapy alone. Descriptive statistics, Kaplan-Meier survival curves and Log-Rank test were used for statistical estimations.The analysis confirmed more favorable prognosis in patient group treated with a combination secondary cytoreduction and chemotherapy. Mean disease-free survival (DFS) was 49.8 months (95% CI; 33.2-66.3) and mean overall survival (OS) stood at 54.0 months (95% CI; 39.4-68.6) in this patient cohort, while in patient group treated with chemotherapy alone it was found that mean DFS was 16.6 months (95% CI; 7.4-25.8) and mean OS stood at 26.2 months (95% CI; 16.6-35.8). When testing the difference between survival curves, statistically significant differences were observed in both DFS (p = 0.010) and OS (p = 0.007) rates between two treatment groups. Age60 years at the time of recurrence and zero macroscopic residual disease after secondary cytoreduction were identified as favorable prognostic factors for both DFS and OS in a multivariate analysis.Secondary cytoreductive surgery is acceptable as a viable treatment option for highly selected women with ovarian cancer recurrence. Complete resection is considered ultimate goal of secondary cytoreduction on condition that the balance between maximal survival gain and minimal operative morbidity will be kept.

Simple Summary Endometrial cancer is common malignancy with an excellent prognosis due to its early symptoms—abnormal bleeding. It is still common in some countries to provide a biopsy in asymptomatic patients based on ultrasound findings; even though, it is not supported by the European guidelines. The aim of our study was to find out if there is a prognostic difference among symptomatic and bleeding-free patients with similar clinical histological characteristics. Abstract Background: Endometrial cancer is the most common gynecological malignancy in developed countries with no screening available. There is still a tendency to provide invasive bioptic verification in asymptomatic women with abnormal ultrasound findings to diagnose carcinoma in a preclinical phase; even though, it is not supported by European guidelines. Our goal was to determine DFS (disease-free survival), OS (overall survival), and DSS (disease-specific survival) differences between symptom-free and symptomatic (bleeding, or spotting) endometrial cancer patients with similar stage and tumor/clinical characteristics. Methods: All of our patients with endometrial cancer following surgical treatment between 2006 and 2019 were assessed, evaluating risk factors for recurrence and death while focusing on bleeding using univariable and multivariable analysis. Results: 625 patients meeting the inclusion criteria were divided into asymptomatic (n = 144, 23%) and symptomatic (n = 481, 77%) groups. The median follow-up was 3.6 years. Using univariable analysis, symptomatic patients had a three times higher risk of recurrence (HR 3.1 (95% Cl 1.24–7.77), p = 0.016). OS (HR 1.35 (0.84–2.19), p = 0.219) and DSS (HR 1.66 (0.64–4.28), p = 0.3) were slightly worse without reaching statistical significance. In our multivariable analysis, symptomatology was deemed completely insignificant in all monitored parameters (DFS: HR 2.03 (0.79–5.24), p = 0.144; OS: HR 0.72 (0.43–1.21), p = 0.216). Conclusions: The symptomatic endometrial cancer patients risk factor of earlier recurrence and death is insignificantly higher when compared with the asymptomatic cohort. However, multivariable analysis verifies that prognosis worsens with other clinically relevant parameters, not by symptomatology itself. In terms of survival outcome in EC patients, we recognized symptomatology as a non-significant marker for the patient’s prognosis.

IntroductionThis study aimed to investigate the possible benefits of a complete cytoreduction in patients with advanced ovarian cancer and concomitant rectal invasion. Furthermore, we evaluated the morbidity associated with radical surgery. Material and methodsA retrospective analysis examined 35 women who underwent radical surgery in the form of modified posterior pelvic exenteration. Descriptive statistics, Kaplan-Meier survival curves and log-rank test were used for statistical estimations. Surgical complications were analyzed using the Clavien-Dindo classification. ResultsThe analysis of survival in relation to residual disease assessed according to Sugarbaker confirmed an optimistic prognosis in patients with optimal debulking with a mean disease-free survival period of 33.6 months in R0 patients, 19.6 months in R1 patients, and 14.3 months in R2 patients. A statistically significant difference in disease-free survival (p = 0.023) was observed between the R0 (without residual disease) and R1+2 (with residual disease) groups. Surgical complications occurred in 83% of patients, with early postoperative complications being most frequent (65.7%). While grade III-IV complications occurred in 37.7% of all patients, no cases of surgery-associated mortality occurred. ConclusionsModified posterior pelvic exenteration is a highly effective method for achieving optimal debulking in cases of advanced ovarian cancer with the direct invasion of the rectum. Modified posterior pelvic exenteration does not delay the beginning of complementary chemotherapy. However, it is necessary to take into account surgery-related morbidity. As modified posterior pelvic exenteration represents an extremely invasive technique, the surgical plan and perioperative care should be personalized to address the individual medical and surgical conditions of each patient.

Objectives: To evaluate risk factors associated with the local recurrence of invasive squamous cell vulvar cancer in patient group with tumor-free pathological margins. Material and methods: This is a retrospective analysis of 47 patients who underwent surgical treatment at University Hospital Brno, the Czech Republic between 2007 and 2014. 24 patients were classified as IB stage and three as II stage. A further 20 patients representing stage III showed the metastatic involvement of regional lymph nodes. Seven prognostic factors were analyzed in relation to local tumour recurrence: tumour size, margin distance, depth of invasion, lymphovascular space involvement (LVSI), midline involvement, metastatic lymph nodes and FIGO stage. Results: All prognostic factors were found to be statistically significant with respect to the risk of local recurrence. The highest risk of local recurrence was observed for the depth of invasion > 5 mm (HR, 12.42 [95% CI; 3.44–44.84]) and for the presence of LVSI (HR, 10.83 [95% CI; 3.87–30.28]). The study also established a clear difference in the risk of local recurrence between patient groups with resection margin < 8 vs. ≥ 8 mm (HR, 4.91 [95% CI; 1.73–13.93; p = 0.003]. Conclusions: Tumour-free pathological margin of ≥ 8 mm is a major prognostic factor of local recurrence which can be influenced by the surgeon. A perfect knowledge of the extent of the disease prior to surgery supports adequately radical surgical trends. The emphasis is given on adequate radicality as well as on the reduction of overtreatment without worse­ning prognosis by simultaneously preserving the quality of life.

Objectives: To describe the ultrasound features of benign Brenner tumor in the background of complex clinical and histopathological pictures. Material and methods: We retrospectively identified patients with histologically confirmed benign Brenner tumor of the ovary who were treated in our institution in 2003–2016, and for whom complete imaging, clinical, perioperative and histopathological data were available in the database. Ultrasound findings were drawn from images and reports using terms and definitions of the International Ovarian Tumor Analysis group and pattern recognition description was applied. Results: Twenty-three patients were identified, most postmenopausal and asymptomatic. On ultrasound, 19/23 tumors were found unilaterally, 4/23 bilaterally, and 82% of tumors were detected in the left ovary. Most Brenner tumors (16/23) contained solid components and revealed no or minimal blood flow by subjective color score upon Doppler examination (19/23, 83%). Calcifications with shadowing were observed in 57% of all Brenner tumors and in 81% of tumors containing solid components. The complex appearance of the tumor misled the sonographers to describe the mass as malignant in 9 cases (39%), and frozen section was performed perioperatively. Surgery was performed via laparoscopy in 11 (48%) and via laparotomy in 12 (52%) cases. Conclusions: The complexity of the ultrasound picture, consisting of features like calcifications with acoustic shadowing, a poorly vascularized solid mass, and a left-sided localization could be signs of a benign Brenner tumor and could preop­eratively help to differentiate between benign and malignant tumor.

Objective To compare the Copenhagen Index (CPH-I) and the Risk of Ovarian Malignancy Algorithm (ROMA) in the differential diagnosis of ovarian tumors. Methods In a retrospective study, data were reviewed from women with ovarian tumors who attended University Hospital Brno, Czech Republic, between July 2011 and June 2015. The women were classified into the benign tumor group or malignant tumor group (borderline and malignant tumors). Serum levels of CA125 and HE4 were extracted from medical records. The two tumor indices were calculated using relevant clinical data. Results Among 267 included women, 110 had benign tumors, 42 had borderline ovarian tumors, and 115 had malignant tumors. The two indices showed similar discriminatory performance with no significant differences (P>0.05). In the differentiation of benign tumors from all stages of borderline tumor and ovarian cancer, ROMA showed a sensitivity of 71% at a specificity of 88%, whereas CPH-I showed a sensitivity of 69% at a specificity of 85%. Conclusion CPH-I is a potential tumor index that is independent of menopausal status. It might be applied as a simple alternative to ROMA in settings of basic medical care.

Aims: To describe the ultrasound features of benign struma ovarii that often mimic ovarian cancer in the background of complex clinical and histopathological pictures.Material and methods: We retrospectively identified patients with histologically confirmed benign struma ovarii, treated in our institution between 2003–2016 with complete imaging, clinical, nd histopathological data available. Ultrasound findings were drawn from images, and reports using terms and definitions of the International Ovarian Tumor Analysis group and pattern recognition description was applied.Results: In all, 19 patients were identified; 10 with pure and 9 with impure struma. Median age was 47 (range 24–69); 10 (53%) were premenopausal. Only four (21%) patients presented with pain, others were asymptomatic. Using pattern recognition, 74% strumas (14/19) were uni-/multilocular solid or solid tumors. The solid components were roundish with smooth contours. Six struma pearls were detected. The subjective color score was moderate or abundant in the majority of solid components. Only 5 (26%) tumors were purely cystic.Conclusions: The ultrasound characteristics differ widely from typical mature ovarian teratoma. Features such as, solid roundish components with smooth contours, struma pearls, acoustic shadowing and occasionally signs of dermoid are clues and may help preoperatively to differentiate benign struma from malignant adnexal lesions.

Background: An ectopic pregnancy within a Cesarean scar represents a rare type of extrauterine pregnancy in which the fertilized egg nidates in the myometrium of the uterine wall within a scar left from a previous Cesarean delivery. An unrecognized growing Cesarian scar pregnancy may result in uterine rupture, uncontrollable metrorrhagia, and bleeding into the abdominal cavity; therefore, early diagnosis and therapy are necessary to prevent the development of severe complications. Case: A 34-year-old woman after a previous Cesarean delivery presented with amenorrhoa of 7 weeks' duration. Transvaginal ultrasonography revealed an ectopic pregnancy in the Cesarean scar, and a laparoscopic removal of the gestational sac was performed with no complications. Results: Three months later, another laparoscopy with chromopertubation showed no signs of penetration in the suture, both the Fallopian tubes being bilaterally passable. The patient was advised that she could try to achieve pregnancy through spontaneous conception, after which monitoring of the gestational development and a careful assessment of the nidation site would be needed. Conclusions: Laparoscopic surgical management of a viable ectopic pregnancy is technically simple, and is followed by a good recovery. (J GYNECOL SURG 30:309)